Oriental Blepharoplasty a Critical Review of.5

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Oriental Blepharoplasty-A Critical Review ofTechnique andPotential HazardsLim Cheng Hin, F.R.C.S.E.The author's experience with Oriental blepharoplasty,comprising 5,000 operations in twelve years, is shared.

Address reprint requests to Dr. Lim, Rm 616, SupremeHouse, Penang Rd, Singapore 0923.

This is one operation in which accuracy and goodjudgement are essential, not to mention the value ofa bit of luck, Although by far the commonest form ofcosmetic surgery in the East, it is also the one thatyields the highest number of unfavorable results andcomplications. I have performed the procedure on noless than 5,000 patients over a twelve-year period,and hope that my experience may serve as a usefulguide to younger, less experienced practitioners ofthis art.

To get consistently favorable results, one mustselect patients very carefully. Specifically, one mustbe fully aware of the anatomical variations that cropup from time to time. The eyelids should be studiedcarefully to make sure there is no partial ptosis, uni-laterally or bilaterally; this is sometimes missed oncursory examination. Look out for scars from previ-ous operations, which the patient sometimes tries toconceal to get a lower fee. (Revision operations carrya higher risk, for obvious reasons.) Out of every 10new blepharoplasty patients I see, 3 have already hadsurgery-once, twice, sometimes even three times.These are people who are already on edge and whotherefore are not ideal candidates. I perform revi-sions only after ..considerable "pleading" from pa-tients, and I get a signed statement absolving me ofresponsibility for all complications and unfavorableresults. To date I have had no trouble from these pa-tients, though I have been only 70% successful inuplifting their spirits.How do we decide when our work is successful,since aesthetics is a matter of personal interpreta-tion? It is true that to qualify as a cosmetic surgeonone must appreciate art. If the line is placed too highit will look unnatural; if placed too low, it may notachieve the surgical objective. All in all, the eyelidsmust look natural once edema has subsided. The bigquestion is "When?" Some patients are good healersand some bad. The swelling can remain from twoweeks (minimum) to six months. Any swelling thatremains after this period is likely to be permanent.During this time there is every likelihood that thepatient will hop from one doctor to another. Thename of the game is patience, and only "tincture oftime" should be prescribed.

To simplify my work I nowadays classify eyes intothree categories: Type I [normal eyes), Type II (puffyeyes), and Type III (sunken eyes), according to visualassessment.

362 0148-7043/81/110362-13$01.25 1981 by Little, Brown and Company [Inc.]


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Lim: .Oriental Blepharoplasty

TypeI-Normal EyesThese are so classified because they look neitherpuffy nor sunken, and good results can always be ex-pected. These patients may be accepted for surgerywithout hesitation. Figures 1 through 5 show Orien-tal blepharoplasty as performed on Type I eyes.TypeII-Puffy EyesPuffiness is due to one of several factors-prominentbony orbital rim; abundance of subcutaneous fat andfibrofatty tissues, hypertrophic lacrimal gland, andabundant extraorbital fat, which is occasionally dueto exophthalmos of thyroid origin. If due to endo-crine disorder, the cosmetic aspect is of secondaryimportance,Because cosmetic results are so unpredictable, pa-tients should not be accepted hastily. A degree ofpuffiness may persist despite routine excisions ofsubcutaneous fibrofatty tissue [pretarsal area in-eluded), orbicularis muscle, and extraorbital fat.Unless patients are forewarned, they will be disap-pointed. A small eye that already looks puffy is evenmore difficult to handle, for in many cases the eyeends up looking smaller still! In dealing with thiseye type, one should make the line quite close to thelash margin, about 3 mm on the average, and alsomake the routine excisions. I do not consider it worth-while to chip off the prominent bony rim even if it Uis responsible for the puffiness, One might have toremove a lot of bone in order to achieve the desiredeffect, and the risk is not worth taking. Hypertrophyof the lacrimal gland is sometimes the cause ofbulging on the lateral side. The superficial portionmay be excised to reduce the bulge, but the wisdomofthis is debatable. To date I have operated on only 9such patients, 4 of whom complained of dry eye syn-drome postoperatively! I would be hesitant today todo another gland resection except for biopsy pur-poses.TypeIII-Sunken EyesThe anatomy of this type must be fully understoodto appreciate the underlying potential hazard. Oneshould not be fooled into believing that just becausetheupper eyelid looks hollowed out, and hence sunk-en, there is very little extraorbital fat. In this typethe fat is almost always "trapped" superiorly, beingbound down by thickened fascia and fibrous bands.

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Fig 1. Skin marking. (A) Assistant pulling up to tenseeyelid skin. (B) Caliper and marker in position. (C) Cen-terpoint marked on right eyelid.


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Annals of Plastic Surgery Vol 7 No 5' November 1981

CFig 2. (AJ Right eyelid marked. Centerpoint started on lefteyelid. (BJAmount of skin tobe resected held by forceps.(C J Testing with [otceps for suitable line.

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CFig 3. (AJ Amount of skin to be resected already markedon right side. (BJMarkings on both sides complete. (C JType I eye showing extra orbital fat.


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Fig4. (A) Eyelid ready for suture. Black silk thread usedto show points of entry and exit in same vertical plane.(8)Suture in position. Patient told to open eye for testing.(C)Extraorbital fat being excised.

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Fig 5. (A) Left eyelid ready for suture. Again, black silkthread used to show points of entry and exit in same ver-tical plane. (B) Immediately after operation. Note posi-tion of eyelash, which is no cause for concern. (e) Oneweek postoperatively. Note position of eyelash now.


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Annals of Plastic Surgery Vol 7 No 5 November 1981

The levator muscle here is often fused with the orbi-tal septum and the orbicularis muscle-thereforelying very close to the skin. Many years ago I wastaught to look for this muscle by first exposing theextraorbital fat, since it lies directly above thelevator. One can imagine how difficult and danger-ous it would be if this rule were adhered to. Quiteoften the levator is exposed first by sharp dissection,by snipping away the fibrous bands and tough fascia.Superiorly the extraorbitalfat is exposed in similarfashion, thus freeing the levator, which noticeablycontracts more strongly. At the same time, the fat soreleased fills up the hollow, giving the eye a morepleasing appearance. There are on the marketsilicone orbital implants for just this purpose; theyshould not be used, for they sometimes cause greatdiscomfort, excessive tearing, and asymmetricalbulging from shifting and rotation over time. Fattransplants from elsewhere in the body work onlytemporarily. The hollow reappears as the fat at-rophies in a matter of months. Surgical release of the Aextraorbital fat still remains the best and most logi-cal procedure.Shapes of Oriental EyesTake a minute to study carefully the shape of eacheye, for, like all paired organs, one never looks thesame as the other. Many of these disparities cannotbe corrected, and this must be made clear to the pa-tient from the start.Unequal SizeOften there is a difference in size, as when the bonyorbital rim of one is larger than that of the other.This should not be' confused' with cases in which,while the rims are about the same size, excess skinover one eye causes hooding to a greater degree overthe palpebral fissure. Whereas the former situationcannot be rectified, the latter can be. Examples ofthe latter are seen in Figure 6. The disparity is moreor less corrected here after blepharoplasty., 'Unequal LengthThis refers to' the length of the palpebral fissure,which varies from 18 mm to 36 mm in my experi-ence. External canthotomy can lengthen this dis-tance,Unequal HeightThe height of the palpebral fissure varies from 5 mm(without evidence of partial ptosis) to about 18 mm,

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1 :lFig 6. Three patients preoperatively (A) and one weekpostoperatively (B).


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the patient's line of vision being at right angles tothe vertical plane. This distance is often increasedafter surgery due to the levator action as it lies an-chored to the skin.Unequal LevelsFrequently observed too is that one eye is higherthan the other, which one cannot do very muchabout (Fig 7A).

Sloping EyesHere the eyes slope either downward toward eachother or upward. Only the latter can be improved,and only to a small degree, by a temple lift, whichtilts the outer canthus upward. I would also like toadd a word about the unilateral "double eyelid."This is present in one eyelid and not the other (seeFig 6C) and is often shallow and incomplete. As it iscommon for patients to want another similar line onthe other eyelid, one should encourage them to haveboth eyelids operated at the same time. A naturallyoccurring line is never as good, as deep, or as long!It is important from the outset to note all thesefeatures and record them, while at the same time

informing patients as to what can and cannot be im-proved.Skin MarkingOnce a patient is accepted for surgery the next im-portant step is marking the skin of the eyelid. Herecertain pitfalls await the inexperienced. It is notsurprising to find that even in IS-year-olds (theyoungest in my experience) there is abundant skin tobe resected.

With the thumb on one eyebrow and the indexfinger on the other the assistant pulls the lids up-ward, tensing the skin to the point where the lashstarts to move up (see Fig IA). With a caliper, a suit-able distance ranging from 3 mm to 10 mm is mea-sured and a centerpoint from the lash marginmarked. From here the line is drawn medially andlaterally in a curved manner, the centerpoint beingfarther from the lash margin than the two ends (seeFigs I, 2). This line is then tested with a pair of for-ceps for suitability. By trial and error a line that willgive the best aesthetic result is chosen.If the skin were not rendered taut, a centerpoint

marked at S mm could very well be at 9 mm whenthe skin is tensed. Among inexperienced surgeonsthis is a common error, resulting in a line that is toohigh and is unnatural. Bad results create anxiety for

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]l,Fig 7 . Three patients with type II.puffy eyes. Preopera-tively (A) and one week postoperatively (B).


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both patient and doctor, and revision operationscarry a high risk; they should be performed eitherone week later when the wound can be reopenedeasily and adhesions have not yet formed, or sixmonths later when swelling has subsided. The ad-vantage of the former is avoidance of the long,traumatic period of waiting and sleepless nights.

A good aesthetic line should extend from the innercanthus to just beyond the outer canthus, with themidpoint farthest away from the lash margin. Whenthis rule is kept in mind, there will be few com-plaints about the line being too short. Never extendthe line beyond the bony orbital rim, as this willleave an unsightly, immobile scar, visible evenwhen the eyes are open. Though it may fade in time,it can also become deeply pigmented, adding morefuel to the fire.

At the inner canthus, requests are often made tomake the line run parallel to and not confluentwith the epicanthic fold, thus making the eye lookmore Caucasian. On numerous occasions such a re-quest was not made, yet the eye turned out this way!My advice is not to accede to such demands but tosay that the anatomy of the eye determines the re-sult. To make a "Caucasian" line I deliberately an-chor the skin to the medial ligament where thelevator is attached; although short-term results aresatisfactory, over time (six months) this line tends tomove closer and finally run confluent with thefold!The Epicanthic FoldCosmetic recontouring of this fold provides quite achallenge. In extreme cases this fold should be ex-cised to improve aesthetic results. Success meansthe palpebral fissure is widened and the lacrimalpunctum exposed. Numerous procedures have beendescribed to eliminate this fold-Z-plasty, W-plasty,simple skin excisions, and more. I use the modifiedZ-plasty in which all loose skin is trimmed off so asto tighten the corner, and expose the punctum.Whatever method is employed, the biggest worry isthe development of keloid scars, as early as in thesecond week. This is very common with Orientalskin. Patients must be told, and if they still want togo through with it, they must be followed closely forup to six weeks. Kenacort injections are given if nec-essary. To be on the safe side it is good to issueprinted instructions to every patient for any kind ofcosmetic procedure immediately after the operation,and have them sign it. It is good practice to as-sume that all patients know little about the proce-

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dure, and we act accordingly. On many occasions myhelp has been sought by patients with keloid scarsfollowing cauthotmy (elimination of the "webbing"of the epicanthic fold over the inner canthus) one ortwo months previously by doctors 'who they claimfailed to inform them of this risk!Local AnesthesiaBlepharoplasty is a precision operation in whichgood judgement is vital. We need all the cooperationwe can get from patients, especially at the time ofsuturing to make sure sutures are placed neither toohigh nor too low. For this reason I never use generalanesthesia.

Tissue distortion, either from bleeding or hema-toma or from too much infiltration with local an-esthesia, must be avoided from the beginning, asthis greatly affects our judgement and hence our re-sults. Experience tells us that punctured vessels in -the orbital area have a nasty habit of bleeding inter-nally, filling up the tissues in no time. If this hap-pens during infiltration, the needle must be with-drawn immediately, and the resulting hematomasqueezed between the thumb and index finger for aminute. This will prevent distortion and infiltrationcan be resumed. I usually use 1% lidocaine withepinephrine 1: 200,000, never more than 4 ml forthe whole procedure (2 ml per side, that is, andsometimes with about 1 ml to spare],

The initial infiltration will take the surgeon rightdown to the orbital septum, exposing the extraorbi-tal fat, which in many textbooks has been describedas having no sensory nerve fibers. This is not true, ofcourse, as handling and cutting it causes pain. Atthis stage I release a few drops of local anestheticover and under the extraorbital fat and wait a min-ute. This usually works well. The anacomisr will de-scribe the extraorbital fat as occupying two or threecompartments, but what is important to us is to de-cide whether or not to remove fat, and how much.The Levator"Look for the extraorbital fat and you will find thelevator" is common advice, but unfortunately theformer is sometimes difficult to find, as in sunkeneyes, and the levator, lying close to the skin, is indanger of being cut. It is in this situation that Mul-ler's muscle can also be accidentally divided. In 1ofmy patients this muscle was severed and partialptosis resulted. Even resuturing did not correct theptosis, which finally resolved over a period of eigh-teen months. Severing the levator alone will not


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Lim: .Oriental Blepharoplasty

- BFigB . (A) Upper eyelid with skin marking. Note midpointfarthest from lash margin. (B) The normal eye (Type I).Crosssection shows extra orbital fat intervening betweenskin and levator. (e) The sunken eye (Type III). Extraor-bital fat "trapped" near the roof and levator fused withorbital septum at point of entry (beware!).

cause ptosis; Muller's muscle must also be impli-cated! . .Of all the muscles in the body, the levator perhaps

ranks as the most elusive in that its appearance con-stantly varies. For example:1 . It commonly appears as a shiny, whitish gray or

bluish gray aponeurosis fanning out to its at-tachments.

2. At times the distal third is completely muscular,and less commonly the whole visible part of themuscle is red and meaty.

3. The levator may be completely covered byfibrous bands and thick' fascia, limiting itsmovement. Poor results are often due to f~ilure todivide these and to. free the muscle.

4. In a number of patients, especially those withsmall eyes, the levator may be seen to be comingat you at right angles instead of at the usual 2 0 to40 degrees it normally makes with the skin. Thislevator-skin angle must be carefully noted at thetime of suturing, for the wider the angle the big-ger the volume of tissues trapped below the lineand the smaller the eye. When operating on smalleyes, therefore, we must be careful not to drawthe line too high. On the average, 3 mm from thelash margin is adequate, and some orbicularis andfibrofattytissues in the pre tarsal region must beremoved to reduce the volume (Fi~s 8, 9).

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Extraorbital fat bounddown by bands and .fascia

151;~1'--- Levator/Muller'Scomplex fusing withorbital septum

A

Levator/Muller'scomplex

,/ Levatorskinangle

_ - -"\-" ILevator' ,I

skinangle

.&=:~~-;;J- Le;;rt'or/Muller'scomplex

BFig 9. (A) The normal eye. Note the narrower levator skinangle. (B) The small eye. Because the levator skin angle iswider, the line marked must be nearer the lash margin.


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The Art of SuturingI would repeat that out of every 10 patients I see forconsultation, 3 have already had one or more opera-tions. The usual complaints are:1. The line is too high and is unnatural. Usually

when this is the case the swelling remains for along time-even years.

2. The line is short and incomplete because thelevator is not correctly mobilized, especially inthe outer canthal region, or the line is drawn tooshort!

3. The scar is too rough due to incorrect apposition,or it looks like a railway track. Need I explain?

One must have the time and patience for suturing.Good alignment of skin edges must be maintained atall times so that the skin-leva tor-skin stitch is in thesame vertical line each time (Figs 4A, B, SA, B). Thecorner stitch at the outer canthus is applied onlyafter adequate clearance of fat and fibrous tissueaway from the levator, thus ensuring a long and ade-quate line. I use 5-0 black silk for skin suturing, re-moving it on the fifth postoperative day. So longas the wounds are kept covered with antibiotic eyeointment, healing is uneventful. Dressings or eyepads are unnecessary. To date there have been nocases of wound infection. Patients return daily forchecking and wound cleansing. They sometimescomplain of blurred vision on the second or thirdpostoperative day. This is transient, however, andClears up in a matter of days as the swelling subsides.The eyelid skin is particularly sensitive after opera-tion, so cosmetics should be avoided for about threeweeks; after this period, only hypoallergenic typesare recommended for another three weeks.

In summary, I would like to recall the followingpoints:1. Study the eyes carefully before undertaking

blepharoplasty, to see which type one is dealingwith; note the dangers attendant with Types IIand III.

2. Sometimes partial ptosis, unilateral or bilater-al, may escape notice, while the patient takes itfor granted that this will be corrected at opera-tion. To avoid any unpleasantness, avoid a quickand cursory examination.

3. Try to .develop a routine for marking the skin sothat a suitable line can be chosen easily given any

. type of eye. Beware of small eyes lest they be-come smaller after surgery!

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4. Too much skin left behind will mar an otherwisegood result. In most cases, some skin must be re-sected, regardless of the patient's age, in order totake up the slack and enhance the result.

5. One must be well versed with anatomical varia-tions in this region, especially concerning ex-traorbital fat and the levator.

6. Always ensure a dry surgical field, stopping allbleeders immediately as one goes along, since tis-sue identification is greatly hampered by bleedingor hematoma, and judgement is seriously affectedby swelling and distortion. To put it bluntly,make sure the diathermy machine is in goodworking order at the start of the operation.

7. Finally, take extra time suturing, making surethat the skin-leva tor-skin stitches are in the samevertical plane.


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Lim: .Oriental Blcpharoplasty

Invited CommentRobert S. Flowers, M.D.The preceding essay might better be called "helpfulhints" and "personal feelings" concerning Orientalblepharoplasty. Very little is said about the tech-nique of fold creation, but several helpful hints areincluded and the main risks rather clearly described.I must, with all due respect to the author, take ex-ception to some of the statements made in the arti-cle.

First, in his opening sentence the author pointsout the value of "luck" in performing Orientalblepharoplasty, yet this is simply not a relevant fac-tor in the results of blepharoplasty. "Luck" insurgery is designed and created, and good aestheticresults rarely occur fortuitiously!

Dr. Hin points appropriately to the importance oflooking for eyelid ptosis, inasmuch as this is a fairlycommon preoperative condition, but eyebrow ptosisis equally important, and both are usually missed oncursory examination.

One of the important "helpful hints" in the articleis the admonition to watch for patients' deceptive-ness in trying to conceal previous surgical proce-dures. It is indeed a mistake for the novice to at-tempt reoperation on cases of fold creation wherethe aponeurosis has been used. Unless the surgeon isexperienced in handling these cases he or she usu-ally ends up shortening the aponeurosis and inadver-tently sectioning Muller's muscle (which of coursecan result in lid ptosis if not adequately repaired).The author points out that the goal in this surgery isto make the eye look natural, but he fails to pointout that an equally important goal should be, not theCaucasianization of the eye, but rather making theOriental eye look more beautiful.

The author's one-week postoperative results failto illustrate this point, and in my opinion the reasonforthis is his failure to adequately handle the medialepicanthus. His classification of the three types of eyesisvalid, but he fails to classify the epicanthus, whichisequally important. In most cases I think his failureto solve the problem of the epicanthal fold in anatural way is responsible for his belief that it is notpossible to determine preoperatively the "inside" or"outside" medial beginning of the lid fold. The au-thor recommends informing the patient "that theanatomy of the eye determines the result," which

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simply is not true. Whether the fold begins above theepicanthus. or beneath it can be accurately deter-mined and anticipated-indeed planned-at thetime surgery is performed. Unless the epicanthalfold is placed in an abnormally high position (whichlooks most unnatural in the Oriental eye), it willhave a tethering effect on the epicanthus and gener-ally result in an operated look, which is unmistak-able. Thus, if the fold is to be placed in a natural posi-tion medially, some modification of the epicanthalfold will be required in some cases for the result tobe graceful and beautiful.

The "temple lift" is suggested as a means of cor-recting "downward slope" of the eye. This techniquehas been attempted for many years and is not effec-tive at all in changing the downward tilt of the in-tercanthal axis. There are a number of effectivemethods for performing a lateral canthopexy, andthese can simply be performed in conjunction withan Oriental blepharoplasty.

Dr. Hin makes a very important point in em-phasizing that the aponeurosis should be identifiedbefore the fat, especially in deep-set eyes and in lidsthat are likely to have a higher attachment betweenthe aponeurosis and the orbital septum. If one con-tinues cutting through the lid looking for the orbitalfat, one can totally transect the lid before identifyingany orbital fat because of its high placement.It is suggested in this article that the hollow eyecan be made less hollow by the dis entrapment of or-

bital fat. If this is true, the effect is most minimal.It is also suggested that edema in the eye lasts two

weeks to six months. Indeed, it is a minimum of sixmonths and usually one year before edema subsidesand the end result is apparent after eyelid surgery ofthis type.

A very important point made by the author is thatthe skin must be uniformly tensed for marking, andthat failure to do so can result in profound asym-metry.

Last, I would strongly disagree with the author'sinsistence that there is "usually abundant skin to beresected," even in IS-year-olds. I find myself resect-ing less and less skin-sometimes even none at all.Skin resection is not necessary for the creation of lidfolds, and resection of a great deal of skin is to bediscouraged in all Orientals, young or old.

Getting an aesthetically pleasing result lies asmuch in correctly positioning the eyebrows-usually through coronal lift-as with blepharo-plasty.One last point I would make is that in the aes-


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thetically pleasing eye, the high point of the fold isnot iri the "midpoint" of the eye; rather, the distancebetween lashline and lid fold should be greatest atmidpoint and should continue approximately at thatlevel all the way across the lid in a lateral direction.It is equally important that the fold become

smaller and come very close to the lid margin me-dially. This will give the best aesthetic result and atthe same time maintain the eye's naturalness andOriental quality. However, when Dr. Hin talksabout making the incision 3 mm above the lashline,he must be making his attachments to the tarsus orto the pre tarsal extension of the aponeurosis, thoughthis is not clear from the photographs shown in thearticle.Honolulu, Hawaii

Oriental Blepharoplasty a Critical Review of.5

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